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Introduction to electronic health records
Are electronic medical records a cure for health care? case study
The importance of electronic health records
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Recommended: Introduction to electronic health records
Chapter One: Introduction
1.0 Introduction
This dissertation report is a systematic review of nurses’ attitudes towards electronic health records. This dissertation report consists of four chapters, which includes Introduction, Method, Results, Discussion and Conclusion.
In Chapter 1, the author will outline the background of the study, problem statement, the aim of the study, research questions, research objectives, and operational definition of terms.
In Chapter 2, the author will highlight the search strategy of the literature which included inclusion and exclusion criteria, the hierarchy of evidence, appraises the methodological quality of the ten original research articles by using the critical appraisal checklist, and how the data were extracted and summarized into a systematic format.
In Chapter 3, the author will present the research findings of the ten articles. This chapter will further describe the pattern of nurses' attitudes towards electronic health records and the difference of nurses' attitudes towards electronic health records based on demographic variables. In addition, the strength and weakness of the methodology also will be criticized in this chapter.
In Chapter 4, the author will discuss the research findings of the ten articles. The author also will
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One of the innovations is computerization of the entire health care system. Formerly, patient health record was documented on paper. With the advancement of technology, paper-based documentation has been gradually being replaced by computerized documentation systems in past two decades. With the implementation of computerized documentation systems, it improved efficiency, safety and quality of patient care, provided faster access to patient's data, reduced error occurs, and also promoted communication between healthcare workers (Jha et al., 2009; Poissant et al.,
This is a critical review of the article entitled “Selecting a Standardized Terminology for the Electronic Health Record that Reveals the Impact of Nursing on Patient Care”. In this article, Lundberg, C.B. et al. review the different standardized terminology in electronic health records (EHR) used by nurses to share medical information to the rest of the care team. It aims at showing that due to the importance of nursing in patient care, there is a great need for a means to represent information in a way that all the members of the multidisciplinary medical team can accurately understand. This standardization varies from organization to organization as the terminologies change with respect to their specialized needs.
Jha, A. K., Burke, M. F., DesRoches, C., Joshi M. S., Kralovec P. D., Campbell E. G., & Buntin M. B. (2011). Progress Toward Meaningful Use: Hospitals’ Adoption of Electronic Health Records. The American Journal of Managed Care, 17, 117-123
Historically, physicians and nurses documented patients’ health information using paper and pencil. This documentation created numerous errors in patients’ medical records. Patient information became lost or destroyed, medication errors occur daily because of illegible handwriting, and patients had to wait long periods to have access to their medical records. Since then technology has changed the way nurses and health care providers care for their patients. Documentation of patient care has moved to an electronic heath care system in which facilities around the world implement electronic health care systems. Electronic health records (EHR) is defined as a longitudinal electronic record of
McBride, S., Delaney, J., & Tietze, M. (2012). Health Information Technology and Nursing. American Journal of Nursing, 112(8). Retrieved from http://www.nursingcenter.com/lnc/pdf?AID=1402619&an=00152258-201301000-00010&Journal_ID=&Issue_ID=
The case study by Elizabeth Layman (2011) is a very comprehensive compilation of the implementation of electronic health records, in relation to the Health Information Services Departments. Through this study Layman documents the conditions to be implemented to achieve satisfactory application of the change-over from the conventional pen and ledger system to computer documentation of patient’s records maintained by health networks.
The purpose of this paper is to discuss how Electronic Medical Records (EMR), affects healthcare delivery. I will discuss the positives and negatives this issue has on healthcare and how it effects the cost and quality for healthcare services. In addition, I will identify any potential trade-offs to cost or quality. Lastly, I will discuss how the EMR affects my job as well as any challenges or opportunities this issue presents.
Paper based health record was considered as gold standard during the early period because it was the main source of patient’s health information, was easy to use and it requires just minimal skill. The patient health records were kept by their providers attached to the bed for the easy access of the documents for patient care. The paper records can be lost during storage affecting patient care, duplication of tests making it more expensive care, doubtful as any person can make an entry without signing the paper and most often it is hard to read. So with the growth of advancement in medicine and technology, paper based health record cannot handle which led to the implementation of electronic health record (EHR), which is in digital format, accessible at any time, convenient, accurate and complete information, reliable, improves productivity as well as reduce health care cost of the patient. It also provides better clinical decision making thus providing better outcomes in patient health, which is the goal of the
this will cause healthcare providers with the training and education needed for clinical documentation improvements to be installed effectively. It is important that having a specialized team who can create solutions towards Clinical Documentation Improvement (CDI) in order to minimize the failures that may occur. In this case, investing in training for the materials/tools necessary for healthcare providers to excel in their work with CDI. Essentially, Clinical Documentation is used throughout the healthcare system for the analysis of care, communication, and medical records. This is important because the information of medical records that healthcare providers are able to access, will help patients track their health conditions. Thus, clinical documentation improvement has a direct impact on patients by providing quality information. On the other hand, the new technological advancements will also be able to address the efficiencies in health care system that differ from paper-based charting. Improving on the quality of information will also have the effect upon the ethical and effectiveness of care that is being provided. This has a significant impact in order to maintain patient care that ensures the documentation is accurate, timely, and reflect within the services provided. Documentation assessments can be utilized so there can be improvements on the education for healthcare providers as they intend implementation standards take effect immediately. In this case, failures must be analyzed so that they will have the ability to comprehend and determine an organization’s strengths and weaknesses
This paper will identify the use of Electronic Health Records and how nursing plays an important role. Emerging in the early 2000’s, utilizing Electronic Health Records have quickly become a part of normal practice. An EHR could help prevent dangerous medical mistakes, decrease in medical costs, and an overall improvement in medical care. Patients are often taking multiple medications, forget to mention important procedures/diagnoses to providers, and at times fail to follow up with providers. Maintaining an EHR could help tack data, identify patients who are due for preventative screenings and visits, monitor VS, & improve overall quality of care in a practice. Nurse informaticists play an important role in the adaptation, utilization, and functionality of an EHR. The impact the EHR could have on a general population is invaluable; therefore, it needs special attention from a trained professional.
Advances in technology have influences our society at home, work and in our health care. It all started with online banking, atm cards, and availability of children’s grades online, and buying tickets for social outings. There was nothing electronic about going the doctor’s office. Health care cost has been rising and medical errors resulting in loss of life cried for change. As technologies advanced, the process to reduce medical errors and protect important health care information was evolving. In January 2004, President Bush announced in the State of the Union address the plan to launch an electronic health record (EHR) within the next ten years (American Healthtech, 2012).
Also, these studies question those who are effected; in this case, those who are most effected, is everyone. Doctors and nurses spend the most time working within these systems, but the information that is put into these systems effects every individual in America, because it is their information. Because nurses are often considered “both coordinators and providers of patient care” and they “attend to the whole patient,” their opinion is highly regarded (Otieno, Toyama, Asonuma, Kanai-Pak, & Naitoh, 2007, p. 210). It is clear that the use of these new systems is much debated, and many people have their own, individualized opinion. This information suggests that when there is a problem in the medical field, those who address it attempt to gather opinions from everyone who is involved before proceeding. It has been proven by multiple studies that this system of record keeping does in fact have potential to significantly improve patient health through efficiency, and it is because of this that the majority of hospitals have already completed, or begun the transfer from paperless to electronic (Otieno, Toyama, Asonuma, Kanai-Pak, & Naitoh,
To effectively use the Electronic Health Record, the nurse needs to have knowledge of technology in addition to clinical competency (Linder, e.tal, 2007). This is a common barrier of implementing the Electronic Health Record. Initially, the conversion from paper charting to electronic charting is frustrating, this is particularly an issue for veteran nurses. Veteran nurses are use to a routine, documenting in pen and paper is the only method of documenting they have ever experienced. Nurses are trained and educated with a protocol-based and systematic methods of caring. The implementation of the Electronic Health Record presents a change in the way nurses care for patients (HIT, 2015). Veteran nurses that have worked in the healthcare system for over 30 years and have always used paper charts, now have to re-learn how to chart with the Electronic Health Record (Anders & Daly, 2010). Understanding the nursing related barriers of implementation of the Electronic Health Record is
William Goossen’s theory can be applied in nursing practice to develop nursing informatics skills and knowledge, as well as develop technological system competencies among nurses to collect, process, retrieve and communicate pertinent information across health care organizations (Goossen, 2000). This theory is highly applicable in addressing matters related to electronic health records, which are currently characterized with issues of privacy and confidentiality in relation to storage, retrieval and reproduction of patient health information. The model also provides broad applicability in guiding research at any clinical setting and contributes to the discipline of nursing by simplifying and enhancing documentation and storage of patient’s health information and by allowing better utilization of nursing resources (Elkind, 2009).
Information and Communication Technology (ICT) has been shown to be increasingly important in the education or training and professional practice of healthcare. This paper discusses the impacts of using ICT in Healthcare and its administration. Health Information technology has availed better access to information, improved communication amongst physicians, clinicians, pharmacists and other healthcare workers facilitating continuing professional development for healthcare professionals, patients and the community as a whole. This paper takes a look at the roles, benefits of Information and Communication Technology (ICT) in healthcare services and goes on to outline the ICT proceeds/equipment used in the health sector such as the
Striating from the research idea to the culmination of the findings, the research process entails many segments, all of which are imperative. By choosing the research methodology, the researchers can formulate the path to be used in conducting the study and reporting the findings. The methodology helps in the search of literature, development of research questions and the creation of the most suitable study design. It also assists in the interpretation of the results and the publication of the findings in journals.